Clinical Features and Long-Term Outcomes of Paediatric-Onset Inflammatory Bowel Disease in a Population-Based Cohort in the Songpa-Kangdong District of Seoul, Korea.

BACKGROUND AND AIMS: The long-term outcomes of paediatric-onset inflammatory bowel disease [pIBD] in non-Caucasian populations are unknown. We therefore evaluated and compared the clinical features and long-term outcomes of pIBD with those of adult-onset IBD [aIBD] using a population-based cohort in the Songpa-Kangdong district of Seoul, Korea. METHODS: Clinical characteristics and prognoses were compared between the two groups: pIBD [defined as <18 years of age at diagnosis] and aIBD [18-59 years of age at diagnosis]. RESULTS: We identified 131 patients with pIBD (48 ulcerative colitis [UC], 83 Crohn's disease [CD]) and 1192 patients with aIBD [866 UC, 326 CD] during 1986-2015. Extensive colitis at diagnosis was more prevalent in pUC than in aUC [45.8% vs 22.3%, p < 0.001], and the overall exposure to corticosteroids, thiopurines and anti-tumour necrosis factor agents was higher in pUC than in aUC [p < 0.001]. The cumulative risk of colectomy was higher in pUC than in aUC during a median follow-up of 125.0 and 112.1 months, respectively [8.9% vs 1.8% at 10 years after diagnosis, p = 0.030]. Ileocolonic location and inflammatory behaviour at diagnosis were more common in pCD than in aCD; however, patients with pCD and aCD did not differ regarding treatment or disease course during a median follow-up of 137.2 and 120.9 months, respectively. CONCLUSION: Our study showed clear differences between pIBD and aIBD, especially in UC. pUC presents with more extensive diseases and may have a more severe disease course, as suggested by an earlier time to administering medications and performing colectomy.

Changes in the Long-term Prognosis of Crohn's Disease between 1986 and 2015: The Population-Based Songpa-Kangdong Inflammatory Bowel Disease Cohort Study.

BACKGROUND/AIMS: The long-term course of Crohn's disease (CD) has never been evaluated in non-Caucasian population-based cohorts. The aim of the present study was to evaluate the longterm prognosis of Korean CD patients in the well-defined population-based Songpa-Kangdong inflammatory bowel disease cohort. METHODS: Outcomes of disease and their predictors were evaluated for 418 patients diagnosed with CD between 1986 and 2015. RESULTS: During a median of 123 months, systemic corticosteroids, thiopurines, and anti-tumor necrosis factor (TNF) agents were administered to 58.6%, 81.3%, and 37.1% of patients, respectively. Over time, the cumulative probability of starting corticosteroids significantly decreased (p=0.001), whereas that of starting thiopurines and anti-TNFs significantly increased (both p<0.001). The cumulative probability of behavioral progression was 54.5% at 20 years, and it significantly decreased during the anti-TNF era. Intestinal resection was required for 113 patients (27.0%). The cumulative probabilities of intestinal resection at 1, 5, 10, 20, and 25 years after CD diagnosis were 12.7%, 16.5%, 23.8%, 45.1%, and 51.2%, respectively. Multivariable Cox regression analysis identified stricturing behavior at diagnosis (adjusted hazard ratio [aHR], 2.70; 95% confidence interval [CI], 1.55 to 4.71), penetrating behavior at diagnosis (aHR, 11.15; 95% CI, 6.91 to 17.97), and diagnosis of CD during the anti-TNF era (aHR, 0.51; 95% CI, 0.35 to 0.76) as independently associated with intestinal resection. The standardized mortality ratio among CD patients was 1.36 (95% CI, 0.59 to 2.68). CONCLUSIONS: The long-term prognosis of Korean patients with CD is at least as good as that of Western CD patients, as indicated by the low intestinal resection rate. Moreover, behavioral progression and intestinal resection rates have decreased over the past 3 decades.

Clinical Characteristics and Long-term Prognosis of Elderly-Onset Ulcerative Colitis in a Population-Based Cohort in the Songpa-Kangdong District of Seoul, Korea.

Background/Aims: We aimed to evaluate the clinical characteristics and long-term prognosis of elderly-onset ulcerative colitis (EOUC) in Korean patients over a 30-year period using a wellestablished population-based cohort in the Songpa-Kangdong district of Seoul, Korea. Methods: Clinical characteristics and prognosis were compared between two groups: EOUC, defined as UC diagnosed in individuals aged ≥60 years and non-EOUC (N-EOUC), defined as UC diagnosed in individuals aged 18 to 59 years. Results: We identified 99 patients with EOUC (10.3%) and 866 patients with N-EOUC (89.7%) between 1986 and 2015. During the median follow-up of 104.5 months, the overall exposure to medications was comparable between patients with EOUC and N-EOUC (p=0.091 for corticosteroids, p=0.794 for thiopurines, and p=0.095 for anti-tumor necrosis factor agents). The cumulative risks of disease outcomes were also comparable between patients with EOUC and N-EOUC (22.4% vs 30.4% for proximal disease extension [p=0.351], 11.9% vs 18.1% for hospitalization [p=0.240], and 2.3% vs 1.8% for colectomy [p=0.977]) at 10 years after diagnosis. Multivariate Cox regression analysis revealed that corticosteroid use at diagnosis was an independent predictor of proximal disease extension (hazard ratio [HR], 6.216; 95% confidence interval [CI], 1.314 to 28.826) and hospitalization (HR, 11.241; 95% CI, 3.027 to 41.742) in patients with EOUC. Conclusions: In this population-based study from Korea, the pattern of medication use seemed comparable between the EOUC and N-EOUC groups. Moreover, patients with EOUC and those with N-EOUC have a similar disease course in terms of proximal disease extension, hospitalization, and colectomy.

Binary Mixtures of Some Active Pharmaceutical Ingredients with Fatty Alcohols-The Criteria of Successful Eutectic Formation and Dissolution Improvement.

Pharmaceutical eutectics are solid mixtures, where the crystals of active pharmaceutical ingredients (APIs) are finely divided in the phase-separated microstructures. The size reduction makes the eutectic formation a viable option to improve the dissolution rate of the poorly soluble APIs. In the present study, ibuprofen, naproxen, and sorafenib were investigated in terms of their phase behaviors with fatty alcohols, such as tetradecanol, octadecanol, and docosanol. Among the studied APIs, only ibuprofen was able to form eutectics with the fatty alcohols, and this was in agreement with the feasibility prediction based on the van 't Hoff equation and solubility parameters. In vitro release behavior was significantly improved for the ibuprofen/octadecanol eutectic mixture, although the practical insolubility of octadecanol in water was the opposite of the outstanding hydrophilicity of usual eutectic formers. The feasibility prediction and the choice of eutectic formers in the present study will be useful in advancing the utility of the pharmaceutical eutectics.

Long-term prognosis of ulcerative colitis and its temporal changes between 1986 and 2015 in a population-based cohort in the Songpa-Kangdong district of Seoul, Korea.

OBJECTIVE: No population-based study has evaluated the natural course of UC over three decades in non-Caucasians. We aimed to assess the long-term natural course of Korean patients with UC in a population-based cohort. DESIGN: This Korean population-based, Songpa-Kangdong IBD cohort included all patients (n=1013) newly diagnosed with UC during 1986-2015. Disease outcomes and their predictors were evaluated. RESULTS: During the median follow-up of 105 months, the overall use of systemic corticosteroids, thiopurines and antitumour necrosis factor (anti-TNF) agents was 40.8%, 13.9% and 6.5%, respectively. Over time, the cumulative risk of commencing corticosteroids decreased, whereas that of commencing thiopurines and anti-TNF agents increased. During follow-up, 28.7% of 778 patients with proctitis or left-sided colitis at diagnosis experienced proximal disease extension. A total of 28 patients (2.8%) underwent colectomy, demonstrating cumulative risks of colectomy at 1, 5, 10, 20 and 30 years after diagnosis of 1.0%, 1.9%, 2.2%, 5.1% and 6.4%, respectively. Multivariate Cox regression analysis revealed that extensive colitis at diagnosis (HR 8.249, 95% CI 2.394 to 28.430), ever use of corticosteroids (HR 6.437, 95% CI 1.440 to 28.773) and diagnosis in the anti-TNF era (HR 0.224, 95% CI 0.057 to 0.886) were independent predictors of colectomy. The standardised mortality ratio in patients with UC was 0.725 (95% CI 0.508 to 1.004). CONCLUSION: Korean patients with UC may have a better clinical course than Western patients, as indicated by a lower colectomy rate. The overall colectomy rate has continued to decrease over the past three decades.

A 30-year Trend Analysis in the Epidemiology of Inflammatory Bowel Disease in the Songpa-Kangdong District of Seoul, Korea in 1986-2015.

BACKGROUND AND AIMS: Although the incidence of inflammatory bowel disease [IBD] is increasing in Asia, data on long-term epidemiological trends are limited. We performed a 30-year longitudinal study to investigate temporal trends in the epidemiology of Crohn's disease [CD] and ulcerative colitis [UC] in Seoul, Korea. METHODS: This population-based study included 1431 IBD patients [418 CD, 1013 UC] diagnosed between 1986 and 2015 in the Songpa-Kangdong district of Seoul, Korea. Temporal trends in incidence, prevalence, and disease phenotype at diagnosis were analysed. RESULTS: The adjusted mean annual incidence rates of CD and UC per 100 000 inhabitants increased from 0.06 (95% confidence interval [CI], 0.05-0.07) and 0.29 [95% CI, 0.27-0.31], respectively, in 1986-1990 to 2.44 [95% CI, 2.38-2.50] and 5.82 [95% CI, 5.73-5.92], respectively, in 2011-2015. Average annual percentage change in IBD incidence was 12.3% in 1986-1995, 12.3% in 1996-2005, and 3.3% in 2006-2015. The male-to-female ratio of the adjusted incidence rate was 3.3:1 for CD and 1.2:1 for UC. Perianal fistula/abscess was present in 43.3% of patients before or at CD diagnosis. At diagnosis, 54.3% of UC patients presented only with proctitis. The adjusted prevalence rate in 2015 was 31.59/100 000 [95% CI, 31.10-32.07] for CD and 76.66/100 000 [95% CI, 75.91-77.42] for UC. CONCLUSIONS: The incidence and prevalence of IBD in Korea have continued to increase over the past three decades. Korean patients have distinct demographic and phenotypic characteristics, including a male predominance and high frequency of perianal fistula/abscess in CD and high proportion of proctitis in UC.

Adverse Events in Hospitalized Pediatric Patients.

: media-1vid110.1542/5789657761001PEDS-VA_2017-3360Video Abstract BACKGROUND: Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). It is unclear whether these efforts have resulted in reductions in hospital-wide AE rates. We used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007-2012) in AE rates among hospitalized children. METHODS: We conducted a retrospective surveillance study of randomly selected pediatric inpatient records from 16 teaching and nonteaching hospitals. We constructed Poisson regression models with hospital random intercepts, controlling for patient age, sex, insurance, and chronic conditions, to estimate changes in AE rates over time. RESULTS: Examining 3790 records, reviewers identified 414 AEs (19.1 AEs per 1000 patient days; 95% confidence interval [CI] 17.2-20.9) and 210 preventable AEs (9.5 AEs per 1000 patient days; 95% CI 8.2-10.8). On average, teaching hospitals had higher AE rates than nonteaching hospitals (26.2 [95% CI 23.7-29.0] vs 5.1 [95% CI 3.7-7.1] AEs per 1000 patient days, P < .001). Chronically ill children had higher AE rates than patients without chronic conditions (33.9 [95% CI 24.5-47.0] vs 14.0 [95% CI 11.8-16.5] AEs per 1000 patient days, P < .001). Multivariate analyses revealed no significant changes in AE rates over time. When stratified by hospital type, neither teaching nor nonteaching hospitals experienced significant temporal AE rate variations. CONCLUSIONS: AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions.

Arylsilylation of aryl halides using the magnetically recyclable bimetallic Pd-Pt-Fe3O4 catalyst.

Transition metal-catalyzed silylations have typically involved the use of homogeneous non-recyclable catalytic systems. In this work, the first example of a recyclable catalytic system for the synthesis of arylsilanes has been reported, which utilizes the bimetallic complex, Pd-Pt-Fe3O4 nanoparticles. Various arylsilanes were prepared by the reaction of aryl iodides (or bromides) with hydrosilanes. This methodology showed good functional group tolerance toward ester, ketone, aldehyde, nitro, and cyano groups. The bimetallic Pd-Pt-Fe3O4 catalytic system showed better activity than monometallic Pt-Fe3O4 and Pd-Fe3O4 catalysts. In addition, the bimetallic Pd-Pt-Fe3O4 catalytic system could be easily recovered and reused for over twenty cycles.

Attributable Cost of Clostridium difficile Infection in Pediatric Patients.

OBJECTIVES The attributable cost of Clostridium difficile infection (CDI) in children is unknown. We sought to determine a national estimate of attributable cost and length of stay (LOS) of CDI occurring during hospitalization in children. DESIGN AND METHODS We analyzed discharge records of patients between 2 and 18 years of age from the Agency for Healthcare Research and Quality (AHRQ) Kids' Inpatient Database. We created a logistic regression model to predict CDI during hospitalization based on demographic and clinical characteristics. Predicted probabilities from the logistic regression model were then used as propensity scores to match 1:2 CDI to non-CDI cases. Charges were converted to costs and compared between patients with CDI and propensity-score-matched controls. In a sensitivity analysis, we adjusted for LOS as a confounder by including it in both the propensity score and a generalized linear model predicting cost. RESULTS We identified 8,527 pediatric hospitalizations (0.53%) with a diagnosis of CDI and 1,597,513 discharges without CDI. In our matched cohorts, the attributable cost of CDI occurring during a hospitalization ranged from $1,917 to $8,317, depending on whether model was adjusted for LOS. When not adjusting for LOS, CDI-associated hospitalizations cost 1.6 times more than non-CDI associated hospitalizations. Attributable LOS of CDI was approximately 4 days. CONCLUSIONS Clostridium difficile infection in hospitalized children is associated with an economic burden similar to adult estimates. This finding supports a continued focus on preventing CDI in children as a priority. Pediatric CDI cost analyses should account for LOS as an important confounder of cost. Infect Control Hosp Epidemiol 2017;38:1472-1477.

Quality of Primary Care for Children With Disabilities Enrolled in Medicaid.

OBJECTIVE: The quality of primary care delivered to Medicaid-insured children with disabilities (CWD) is unknown. We used the newly validated CWD algorithm (CWDA) to examine CWD prevalence among Medicaid enrollees 1 to 18 years old, primary care quality for CWD, and differences in primary care quality for CWD and non-CWD. METHODS: Cross-sectional study using 2008 Medicaid Analytic eXtract claims data from 9 states, including children with at least 11 months of enrollment (N = 2,671,922 enrollees). We utilized CWDA to identify CWD and applied 12 validated or endorsed pediatric quality measures to assess preventive/screening, acute, and chronic disease care quality. We compared quality for CWD and non-CWD unmatched and matched on age, sex, and number of nondisabling chronic conditions and outpatient encounters. RESULTS: CWDA identified 5.3% (n = 141,384) of our study population as CWD. Care quality levels for CWD were below 50% on 8 of 12 quality measures (eg, adolescent well visits [44.9%], alcohol/drug treatment engagement [24.9%]). CWD care quality was significantly better than the general population of non-CWD by +0.9% to +15.6% on 9 measures, but significantly worse for 2 measures, chlamydia screening (-3.4%) and no emergency department visits for asthma (-5.0%; all P < .01 to .001). Differences in care quality between CWD and non-CWD were generally smaller or changed direction when CWD were compared to a general population or matched group of non-CWD. CONCLUSIONS: One in 20 Medicaid-insured children is CWD, and the quality of primary care delivered to CWD is suboptimal. Areas needing improvement include preventive/screening, acute care, and chronic disease management.

Apnea in the Otherwise Healthy, Term Newborn: National Prevalence and Utilization during the Birth Hospitalization.

OBJECTIVES: To describe the prevalence of apnea in otherwise healthy term newborns, identify attributable length of stay (LOS) and healthcare utilization (cost) of apnea, and measure hospital variation in attributable LOS and cost of apnea in this population. STUDY DESIGN: We conducted a secondary analysis of a national administrative dataset, the 2012 Kids' Inpatient Database, which included 3.4 million newborn discharges in the US. The birth hospitalizations of approximately 2.6 million otherwise healthy, full-term newborns were included for analysis. Attributable LOS and cost of apnea were calculated using multivariate analyses. RESULTS: Apnea was diagnosed in 1 in 1000 healthy full-term newborns. Multivariate analyses showed that newborns with apnea had 0.6 days longer LOS (P < .001) and $483 greater costs (P < .001) compared with healthy term newborns, per birth hospitalization. Newborns diagnosed with apnea plus hypoxia and/or bradycardia had 1.4 days longer LOS (P < .001) and $653 greater costs (P < .001). The attributable LOS and cost attributable to apnea varied between individual hospitals and differed by hospital region. CONCLUSIONS: Apnea is associated with higher LOS and cost in the newborn hospitalization, with variation in hospital practice. This suggests the need for better comprehension of the underlying physiology and standardization of practice in its management in the term newborn.

The Associations Between Forced Sex and Severe Mental Health, Substance Use, and HIV Risk Behaviors Among Asian American Women.

We examined the association between forced sex history and mental health, sexual health, and substance use among Asian American women ( n = 720); 14.3% of our sample ( n = 103) reported forced sex experiences. Multiple logistic regression analyses revealed that participants with forced sex histories were 2-8 times more likely to have higher rates of mental health problems, HIV risk behavior, and substance use. Qualitative analysis was used to supplement the quantitative results and give depth to our findings. Our results suggest that interventions for Asian American women who experienced forced sex should integrate mental health, substance use, and sexual health treatments.

Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool.

BACKGROUND AND OBJECTIVE: Efforts to advance patient safety have been hampered by the lack of high quality measures of adverse events (AEs). This study's objective was to develop and test the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool, which measures hospital-wide rates of AEs and preventable AEs. METHODS: Through a literature review and expert panel process, we developed a draft trigger tool. Tool performance was tested in 16 academic and community hospitals across the United States. At each site, a primary reviewer (nurse) reviewed ∼240 randomly selected medical records; 10% of records underwent an additional primary review. Suspected AEs were subsequently evaluated by 2 secondary reviewers (physicians). Ten percent of records were also reviewed by external expert reviewers. Each trigger's incidence and positivity rates were assessed to refine GAPPS. RESULTS: In total, 3814 medical records were reviewed. Primary reviewers agreed 92% of the time on presence or absence of a suspected AE (κ = 0.69). Secondary reviewers verifying AE presence or absence agreed 92% of the time (κ = 0.81). Using expert reviews as a standard for comparison, hospital-based primary reviewers had a sensitivity and specificity of 40% and 91%, respectively. As primary reviewers gained experience, their agreement with expert reviewers improved significantly. After removing low-yield triggers, 27 and 30 (of 54) triggers met inclusion criteria to form final manual and automated trigger lists, respectively. CONCLUSIONS: GAPPS reliably identifies AEs and can be used to guide and monitor quality improvement efforts. Ongoing refinement may facilitate future interhospital comparisons.

Incidence of Stevens-Johnson Syndrome and Chemical Burns to the Eye.

PURPOSE: This population-based observational study was designed to estimate the incidence and distribution of SJS-spectrum (Stevens-Johnson syndrome, toxic epidermal necrolysis, and toxic epidermal Necrolysis/Stevens-Johnson syndrome overlap) and chemical burns (alkali or acid burn of the cornea/conjunctiva) in the United States and extrapolate these numbers to the world. METHODS: All patients evaluated in 961 hospital-based US emergency departments between July 1, 2010, and June 30, 2012 were identified retrospectively using the Nationwide Emergency Department Sample (NEDS) from the Agency for Healthcare Research and Quality. SJS-spectrum and chemical burn cases were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. RESULTS: A mean of 3834 new SJS-spectrum cases per year were identified in the United States, resulting in an incidence rate of 12.35 new cases per million per year. Similarly, a mean of 15,865 new chemical burn cases per year were identified, resulting in an incidence rate of 51.10 new cases per million per year. CONCLUSIONS: If the incidence of SJS-spectrum is approximately uniform the world-over, extrapolation from the US figure would amount to approximately 86,500 new cases per year in the world. Extrapolation of ocular chemical burns to the world is difficult because the incidence and severity are anticipated to be higher in the developing world than in the United States. Still, using a US incidence rate, a minimum of 357,710 burn accidents would be expected to occur worldwide every year; there are presently too few data available to calculate the degree of severity and bilaterality.

The Public Health Impact of Pediatric Deep Neck Space Infections.

OBJECTIVE: There is little consensus about the best management of pediatric deep neck space infections (DNSIs) and limited information about the national disease burden. The purpose of this study is to examine the health care burden, management, and complications of DNSIs from a national perspective. STUDY DESIGN: Retrospective administrative data set review. SETTING: National pediatric admission database. SUBJECTS AND METHODS: Pediatric patients diagnosed with a parapharyngeal space and/or retropharyngeal abscess were identified from the 2009 KIDS' Inpatient Database. Patient demographic, hospital, and clinical characteristics were compared between patients who received surgical and nonsurgical management. All results for the analyses were weighted, clustered, and stratified appropriately according to the sampling design of the KIDS' Inpatient Database. RESULTS: The prevalence of DNSIs was 3444 in 2009, and the estimated incidence was 4.6 per 100,000 children. The total hospital charges were >$75 million. The patients who were drained surgically had a 22% longer length of stay (mean = 4.19 days) than that of those who were managed without surgery (mean = 3.44 days). Mean hospital charges for patients who were drained surgically were almost twice those of patients who were managed medically ($28,969 vs $17,022); 165 patients (4.8%) had a complication. RESULTS: There are >3400 admissions for pediatric DNSIs annually, and they account for a significant number of inpatient days and hospital charges. A randomized controlled trial of management may be indicated from a public health perspective.

Same-Hospital Readmission Rates as a Measure of Pediatric Quality of Care.

IMPORTANCE: Health care systems, payers, and hospitals use hospital readmission rates as a measure of quality. Although hospitals can track readmissions back to themselves (hospital A to hospital A), they lack information when their patients are readmitted to different hospitals (hospital A to hospital B). Because hospitals lack different-hospital readmission (DHR) data, they may underestimate all-hospital readmission (AHR) rates (hospital A to hospital A or B). OBJECTIVES: To determine the prevalence of 30-day pediatric DHRs; to assess the effect of DHR on readmission performance; and to identify patient and hospital characteristics associated with DHR. DESIGN, SETTING, AND PARTICIPANTS: We analyzed all-payer inpatient claims for 701,263 pediatric discharges (patients aged 0-17 years) from 177 acute care hospitals in New York State from January 1, 2005, through November 30, 2009, to identify 30-day same-hospital readmissions (SHRs), DHRs, and AHRs. Data analysis was performed from March 12, 2013, through April 6, 2015. We compared excess readmission ratios (calculated per the Medicare formula) using SHRs and AHRs to determine what might happen if the federal formula were applied to a specific state and to evaluate how often hospitals might accurately anticipate-using data available to them--whether they would incur penalties (excess readmission ratio >1) for readmissions. Using multivariate logistic regression, we identified patient- and hospital-level predictors of DHR vs SHR. MAIN OUTCOMES AND MEASURES: The proportion of DHRs vs SHRs, AHR and SHR rates, and excess readmissions. RESULTS: Different-hospital readmissions constituted 13.9% of 31,325 AHRs. At the individual hospital level, the median (interquartile range) percentage of DHRs was 21.6% (12.8%-39.1%). The median (interquartile range) adjusted AHR rate was 3.4% (3.0%-4.1%), 38.9% higher than the median adjusted SHR rate of 2.5% (2.0%-3.4%) (P < .001). Excess readmission ratios using SHRs inaccurately anticipated penalties (changed from >1 to ≤ 1 or vice versa) for 20 of the 177 hospitals (11.3%); all were nonchildren's hospitals and 18 of 20 (90.0%) were nonteaching hospitals. Characteristics associated with higher odds ratios (ORs) (reported with 95% CIs) of DHR in multivariate analyses included being younger (compared with age <1 year, ORs [95% CIs] for the other age categories ranged from 0.76 [0.66-0.88] to 0.85 [0.73-0.99]); being white (ORs [95% CIs] for nonwhite race/ethnicity ranged from 0.74 [0.65-0.84] to 0.88 [0.79-0.99]); having private insurance (1.14 [1.04-1.24]); having a chronic condition indicator for a mental disorder (1.33 [1.13-1.56]) or a disease of the nervous system (1.37 [1.20-1.57]) or circulatory system (1.20 [1.00-1.43]); and admission to a nonchildren's (1.62 [1.01-2.60]), urban (ORs for nonurban hospitals ranged from 0.35 [0.24-0.52] to 0.36 [0.21-0.64]), or lower-volume (0.73 [0.64-0.84]) hospital (P < .05 for each). CONCLUSIONS AND RELEVANCE: Different-hospital readmissions differentially affect hospitals' pediatric readmission rates and anticipated performance, making SHRs an incomplete surrogate for AHRs-particularly for certain hospital types. Failing to incorporate DHRs into readmission measurement may impede quality assessment, anticipation of penalties, and quality improvement.

Recognizing Differences in Hospital Quality Performance for Pediatric Inpatient Care.

BACKGROUND: Hospital quality-of-care measures are publicly reported to inform consumer choice and stimulate quality improvement. The number of hospitals and states with enough pediatric hospital discharges to detect worse-than-average inpatient care remains unknown. METHODS: This study was a retrospective analysis of hospital discharges for children aged 0 to 17 years from 3974 hospitals in 44 states in the 2009 Kids' Inpatient Database. For 11 measures of all-condition or condition-specific quality, we assessed the number of hospitals and states that met a "power standard" of 80% power for a 5% level significance test to detect when care is 20% worse than average over a 3-year period. For this assessment, we approximated volume as 3 times actual 2009 admission volumes. RESULTS: For all-condition quality, 1380 hospitals (87% of all pediatric discharges) and all states met the power standard for the family experience-of-care measure; 1958 hospitals (95% of discharges) and all states met the standard for adverse drug events. For condition-specific quality measures of asthma, birth, and mental health, 203 to 482 hospitals (52%-90% of condition-specific discharges) met the power standard and 40 to 44 states met the standard. One hospital and 16 states met the standard for sickle cell disease. No hospital and ≤27 states met the standard for the remaining measures studied (appendectomy, cerebrospinal fluid shunt surgery, gastroenteritis, heart surgery, and seizure). CONCLUSIONS: Most children are admitted to hospitals in which all-condition measures of quality have adequate power to show modest differences in performance from average, but most condition-specific measures do not. Policies regarding incentives for pediatric inpatient quality should take these findings into account.

Hospitalizations in children with preexisting tracheostomy: a national perspective.

OBJECTIVES/HYPOTHESIS: To describe the reasons for hospitalization and characteristics of children with preexisting tracheostomy and to compare hospital utilization between children with and without tracheostomy. STUDY DESIGN: Retrospective cohort study. METHODS: Children with tracheostomy were selected in the Healthcare Cost and Utilization Project Kids' Inpatient Database 2009 using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We compared hospital utilization with the children's clinical characteristics (e.g., chronic condition number and type). We also assessed hospitalizations for tracheostomy complications and ambulatory care sensitive conditions (ACSCs) that could be potentially influenced by high-quality outpatient and community care delivery. RESULTS: In 2009, there were 21,541 hospitalizations for children with tracheostomy totalling $1.4 billion (U.S.). On average, children with tracheostomy had five chronic conditions (standard deviation 1.4). Eighty-one percent (n = 17,448) had one or more complex chronic conditions (CCCs), and 67.1% (n = 14,379) had a gastrostomy. Among children with one or more CCCs, mean hospital charges were greater for hospitalizations of children with tracheostomy compared to without ($69,999 vs. $64,017, P = 0.008). Twenty-one percent (n = 4,421) of all hospitalizations of children with tracheostomy were due to an ACSC (14.5%, n = 3,122) or a tracheostomy complication (6.0%, n = 1,299). Bacterial pneumonia (9.6% of all hospitalizations, n = 2,059) was the most common ACSC. CONCLUSIONS: Children with tracheostomy are a vulnerable group of children with multiple CCCs who experience lengthy and costly hospitalizations. Many hospitalizations are due to an ambulatory care sensitive condition or a tracheostomy complication. Further investigation is needed to determine whether some of these hospitalizations may be avoidable with improved outpatient and community tracheostomy care. LEVEL OF EVIDENCE: 2b.

Radiology trainees' comfort with difficult conversations and attitudes about error disclosure: effect of a communication skills workshop.

PURPOSE: The aim of this study was to assess the effect of communication skills training on radiology trainees' (1) comfort with communicating directly with patients and family members about unexpected or difficult diagnoses ("bad news"), radiologic errors, and radiation risks and (2) attitudes about disclosing radiologic errors directly to patients and their families. METHODS: One hundred nine radiology trainees from 16 US programs were asked to complete questionnaires immediately before and after attending an institutional review board-exempted, full-day communication workshop. Questionnaires assessed (1) comfort communicating with patients and their families generally and about bad news, radiologic errors, and radiation risks specifically; (2) attitudes and behavioral intent regarding a hypothetical vignette involving a radiologic error; and (3) desire for additional communication training. RESULTS: All trainees completed the questionnaires. After completing the workshop, more trainees reported comfort communicating with patients about bad news, errors, and radiation risks (pre vs post, 44% vs 73%, 25% vs 44%, and 34% vs 58%, respectively, P < .001 for all). More also agreed that the radiologist in the error vignette should discuss the error with the patient (pre vs post, 84% vs 95%; P = .002) and apologize (pre vs post, 78% vs 94%; P < .001). After participation, fewer trainees reported unwillingness to disclose the error despite medicolegal concerns (pre vs post, 39 vs 15%; P < .001). Despite high baseline comfort (92%) and low stress (14%) talking with patients in general, most respondents after participation desired additional communication training on error disclosure (83%), general communication (56%), and radiation risks (80%). CONCLUSIONS: This program provides effective communication training for radiology trainees. Many trainees desire more such programs.

Drug use and suicidality among Asian American women who are children of immigrants.

This study investigates the association between drug use and lifetime suicidal behaviors among Asian American women (n = 720) residing throughout Massachusetts, using data collected from 2010 to 2011. Logistic regression models identified that a history of hard drug use alone or in combination with soft drug use has a significant association with both suicidal ideation and suicide attempts among Asian American women, adjusting for demographic covariates, history of psychiatric diagnosis, and family communication. These findings highlight the importance of addressing hard drug use when designing suicide prevention programs for Asian American women.